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Leaving no one behind: Reflections from South Africa’s response to migration and health

By Thea de Gruchy
on April 19, 2019

Many countries, including South Africa, have committed to the Sustainable Development Goal (SDG) of achieving Universal Health Coverage (UHC). South Africa’s potential to achieve this goal is however limited by its reluctance to provide health care to non-nationals.

As part of its efforts to achieve UHC, South Africa hopes to implement a National Health Insurance scheme. However, in its current form, under the proposed scheme, non-nationals, including documented refugees and asylum seekers, would have far fewer rights to health care than they currently do. While this short piece reflects on South Africa specifically, it would be remiss not to acknowledge that this is a reflection of global trends; anti-migrant politics and policies appear to be the one thing around which people can unite in 2019.

As it stands, everyone in South Africa, regardless of their nationality or documentation, is entitled to free primary healthcare, including HIV and TB treatment. All health services are free for pregnant and lactating women and children under six, while refugees and asylum seekers, alongside South Africans and South African Development Community (SADC) nationals, are means tested for higher levels of care. Non-nationals from outside SADC, who are not refugees or asylum seekers, pay in full for higher levels of care.

However, while migrant populations are not explicitly excluded from the healthcare system, policies and programmes are not sufficiently migration aware. As a result, programmes are not designed to take into account the realities of the barriers that migrants may face if and when they try to access health care. This has obvious implications for the health of both internal and cross-border migrants, as health systems aren’t designed to consider the reality that patients may need to access care and pick up medication in different parts of the country, or region, as they travel for work or go home over Christmas.

Where they do exist, efforts to overcome these barriers are piecemeal and reliant on non-state actors. As part of my PhD, I have recently undertaken research on two initiatives that aimed to improve the access that migrant farm workers, working and living along the South African border with Zimbabwe, had to health care. In 2008, in the wake of electoral violence and the outbreak of cholera in Zimbabwe, many Zimbabweans moved across the border and into the area, bringing with them humanitarian agencies and development organisations. After addressing the immediate humanitarian needs of the new arrivals, organisations looked to implement longer term projects. Two of these interventions – a mobile clinic programme developed by Médecins sans Frontières (MSF) and the training of a cohort of community-based peer educators by the International Organization for Migration (IOM) – went someway to improve awareness of and access to primary care, including HIV care, for migrant farm workers in this area.

However, since these organisations have left the area, the programmes have struggled. The mobile clinic programme was handed over to the local Department of Health and incorporated into the work undertaken by the Department in the area. Unfortunately, this has not translated into a continuation of the material or political support that the programme had during MSF’s involvement. Simultaneously, the IOM-trained peer educators have struggled to maintain momentum. While they were always a volunteer workforce, during IOM’s involvement in the area they were sent on training and involved in the organisation of activities and events within the community. Without any financial support, these small, but necessary, incentives have come to an end, and frustration over the lack of compensation for the work has set in.    

Critiques of aid and development interventions have long pointed to the sustainability of such interventions as a concern. In a recent article in Global Public Health, Anuj Kapilashrami and I argue, specifically in relation to the MSF intervention, that the reliance on such an unsustainable model puts achieving UHC in South Africa, as well as globally, at risk. Targeted interventions such as these, while understandably necessary during times of crisis, do little more than bandage gaps in the health care system, and in so doing delay the necessary broader restructuring needed to ensure more inclusive access.

To enjoy the developmental benefits of migration, as Vearey and others have argued, and to ensure that no one is left behind as we work to ‘ensure healthy lives and promote wellbeing for all at all ages’, policy and programmes (including, for example, the proposed South African National Health Insurance) need to be migration aware at the outset.

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